Métodos de cálculo de resonancias

Review of the healthcare delivery system must be an ongoing and iterative process. As Hudson Valley healthcare costs rise and its outcomes stagnate, a coordinated regional planning effort must evolve. In 2005, the Commission on Healthcare Facilities in the 21st Century, otherwise known as the Berger

Commission, was formed to review New York’s healthcare resources and capacity. It was intended to “ensure that the regional and local supply of hospital and nursing home facilities is best configured to appropriately respond to

community needs for high-quality, affordable, and accessible care, with meaningful efficiencies in delivery and financing that promote infrastructure stability.”106 _{In other words, the Commission was to promote “rightsizing,” or} properly shaping the healthcare services and resources to the demographic needs of the region. Rightsizing can include consolidation, closure, conversion, restructuring, and reallocation. The Commission caused a few hospitals to alter their bed configurations, and eliminated almost 3,000 SNF beds.107 In the Hudson Valley region, the Berger Commission had a significant impact in Ulster County by recommending that Benedictine Hospital (a Catholic hospital) and Kingston Hospital (a secular hospital) align to reduce bed numbers and reduce the high rate of outmigration. As a result, HealthAlliance of the Hudson Valley was formed, merged the two hospitals functionally and is now facing the decision of whether to further consolidate operations into a single campus. Despite the Berger Commission’s effort, regional outcomes have not improved and costs have continued to escalate.

While no regional health planning organizations currently exist in the Hudson Valley, we would be remiss if we did not highlight two regional entities that not only seek to improve the regional healthcare delivery system, but assisted us in the preparation of this work by providing data and insight. The Northern

Metropolitan Hospital Association (NorMet) is a nonprofit hospital membership regional organization which acts as an information clearinghouse, pursues governmental relations activities and advocacy, and acts as liaison with

regulatory and health-related agencies. The Taconic Health Information Network and Community (THINC) is a nonprofit organization that seeks to improve the quality, safety and efficiency of Hudson Valley healthcare primarily through its emphasis on the adoption and integration of information technology.

106

Commission on Health Care Facilities in the 21st Century. Retrieved from http://www.nyhealthcarecommission.org/.

107

New York State Department of Health. (2009). Report on Implementation of the Report of the Commission

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In 2012, Governor Andrew Cuomo charged the New York State Public Health and Health Planning Council (PHHPC) with evaluating the CON process. The PHHPC sought to pursue the “Triple Aim” of better care, better health and lower per capita costs. They evaluated other states that use a different process for licensing facilities as well as states that do not have a CON process at all. One result of the work of the PHHPC was a call for regional health planning.

The PHHPC defined regional health planning as a three part process: 1) Create multi-stakeholder collaboratives to pursue the Triple Aim 2) Analyze and display data in an objective manner

3) Provide recommendations to the PHHPC on CON determinations New York state has two Health Service Agencies that currently do regional health planning and weigh in on CON decision-making.108 The Hudson Valley had a Hudson Valley Health Services Agency operating as late as 1988 but it has since been disbanded.109 In his 2014 State of the State address the Governor

discussed creating 11 Regional Health Improvement Collaboratives (RHICs). Healthcare delivery system and public health planning would be improved through the formation of a RHIC or some other regional health planning effort and the associated work of such an entity.

The PHHPC’s recommendations included maps for potential health planning regions. The proposed Hudson Valley region included seven of the nine counties included in this Project.

Figure 16. PHHPC’s Health Planning Regions

Source: Report of the Public Health and Health Planning Council on Redesigning Certificate of Need and Health Planning

108

The Finger Lakes and Central New York have well funded and staffed HSAs that serve as RHICs. The Finger Lakes HSA and HealtheConnections.

109

Pattern for Progress played a role convening and facilitating efforts to that resulted in the creation of the Hudson Valley HSA in 1978.

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There are several types of data available from New York State that define the Hudson Valley as the seven-county region and group Greene and Columbia Counties with the Albany region. Governor Cuomo’s Mid-Hudson Regional Economic Development Council (MHREDC) also defines the Hudson Valley as a seven-county region.110

The purpose of this report was to analyze the impact of the aging population on the region’s healthcare system. Although the work of this Project did not start out with the goal of regional health planning, the Project did engage a multi-

stakeholder group to analyze data in an objective manner. It is the hope of the Project and the Advisory Panel, that this work sets the stage for additional regional health planning.

It is our belief that the evaluation of service availability provides great value in planning for the Hudson Valley’s collective future not just in terms of DOH licensure of SNF and hospital beds but in planning bed types, investments in building capacity to provide certain types of services, and needed workforce training and recruitment. Ultimately the cost and quality of care in the region will depend on such an effort.

Future regional health planning will require substantial sustained investment in organizational capacity. While THINC covers the Hudson Valley region as defined by the Governor’s proposed regional health planning structure and undertakes projects related to health systems change, it does not currently have the staffing capacity to conduct this work without additional resources. While Pattern for Progress was able to conduct this work, continued work of this nature would require new funding sources. It is possible that an entirely new entity or collaboration among existing entities would be best poised to conduct regional health planning going forward. Since New York State’s regional health planning effort may be enhanced through funding opportunities later this year or next, it is beneficial that the region has begun this discussion now.

RECOMMENDATION: The Hudson Valley should begin its regional health planning effort in earnest. Regional health planning data must be

centralized and consensus among providers reached, to ensure limited duplication of services as well as care coordination between the various institutions comprising the continuum of care. Further consolidation of these various components into integrated delivery systems as seen in the high performance innovative systems will facilitate this effort.

110 _{When the Regional Council process was created, a new more flexible pool of economic development funding} became available, and for the first time, healthcare-related institutions became eligible for economic

development funding. Indeed, the MHREDC has prioritized and since funded multiple healthcare-related projects over the last three funding cycles. One criticism of this has been that the economic development stakeholders are not equipped to determine the need for expanded or new healthcare delivery facilities.

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INTEGRATION

The model innovative healthcare systems achieved continuous improvements through the analysis of health data. These improvements required the

establishment of uniform metrics to make both physician-level and institution- level comparisons. The improvements also required investment in robust electronic health records (EHR) systems and a cultural shift to embrace change based on data analysis.

Three of the innovative systems examined were in Wisconsin. It should be noted that New York State regulates healthcare differently than Wisconsin in many ways. For example, New York disallows private equity in healthcare and passes Medicaid on to the counties. Also, Wisconsin is a more homogenous state and that may have facilitated the integration of health systems in Wisconsin.

The State of Wisconsin implemented a substantive public health data information sharing initiative to spur improvements. In 2003, chief executives from

Wisconsin’s healthcare provider entities formed the Wisconsin Collaborative for Healthcare Quality (WCHQ).111 The Collaborative, which grew to encompass physician groups, hospitals, employers, labor groups and health plans, developed a common set of reportable metrics that collects and publishes physician-level comparative information on a variety of conditions and quality. This voluntary reporting created a unique set of ambulatory care measures that enable medical groups to collect and report data on all patients in their practice. In addition to the WCHQ, Wisconsin is home to the Wisconsin Health Information Organization (WHIO) Health Analytics Exchange, which has integrated the nation’s largest repository of multi-payer claims data with analytical query tools.112 The transparency achieved in Wisconsin’s collaboration and public information exchange has made it a top region in the country for healthcare outcomes.113

The Centers for Medicare and Medicaid Services (CMS) has also pressed to make health outcomes data public. The Project drew information on hospital outcomes from the Medicare Compare portal, and CMS will be adding even more indicators over the next several years. While there is debate in the health policy literature about whether information such as readmissions rates really provide a window into quality of care, making this data public at least begins the

discussion. The ability to make data public requires the data to be available in the first instance. Better data management is needed for analysis both within individual healthcare organizations and within the region.

111

The Wisconsin Collaborative for Healthcare Quality, http://www.wchq.org/about/. 112

Wisconsin Health Information Organization, http://www.wisconsinhealthinfo.org/link_main.php. 113

The Commonwealth Fund. (2009). Aiming Higher for Health System Performance. P. 9.

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Robust electronic health records systems allow the innovative health institutions to track expensive conditions, share patient data among providers, track areas of larger spending and focus on specific areas for improvement. The region must determine the best ways to make larger, more comprehensive investments in these systems, whether through improved collaboration or the creation of

integrated systems. Current Hudson Valley efforts to implement electronic health record systems may have created billing efficiencies and improved

documentation, but did so at the expense of provider productivity, measurable improvement in quality outcomes and interoperability.

Further large scale investments are needed if EHR are to be used to improve care, increase provider productivity and allow regional analysis. The many-to- many relationships among providers complicate information sharing.

Furthermore, large investments in newer robust EHRs are limited by the persistence of many smaller one- or two-person private medical practices that simply cannot afford them. Larger integrated systems are able to make the necessary investments in electronic health records infrastructure. For example, between 1998 and 2008 Gundersen invested over $100 million in improvements to its EHR systems.114 The Everett Clinic budgeted $18 million over three years to update its EHR system.115 These investments allow sharing of data among providers, whether or not they are in a single system. In addition, EHR can result in substantial savings and better care. For example, Gundersen saw an

impressive reduction in laboratory tests of 16%, largely as a result of eliminating duplicate testing.116 In addition, EHR is being used in innovative ways to

implement preventative public health measures such as directing patient smokers to smoking cessation programs and medications.117 ThedaCare uses disease registries as part of the EHR system that allow tracking of patients, benchmarking them against other patients as well as state and national averages. Data analysis also allows health providers to look directly at costs. For example, the Dean Clinic found that only 6% of its spending was for direct costs of providing primary care, yet 80% of their total patient costs were driven by primary care physicians through their ordering of tests, procedures, medications and referrals.118

Healthcare data in the Hudson Valley is largely fractured and inefficient. The Hudson Valley has an EHR effort involving multiple providers now underway.

114 _{Klein, S. and McCarthy, D. (2009). Gundersen Lutheran Health System: Performance Improvement through}

Partnership. Commonwealth Fund (pub 1307). Vol. 28. P. 4.

115

Healthcare Financial Management Association. (2010). Leadership: Collaborating for Results, Developing

Meaningful EHR.

116 Id.

117 _{C. Lindholm, et al. (2010, December). A Demonstration Project for Using the Electronic Health Record to} Identify and Treat Tobacco Users. WMJ. 109(6): 335–340. Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3587763/. 118

Molpus, J. (2013, April 22). How Dean Clinic Redesigned Primary Care. Health Leaders Media. Retrieved from http://www.healthleadersmedia.com/print/LED-291352/How-Dean-Clinic-Redesigned-Primary-Care.

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The EHR effort, spearheaded by THINC, seeks to share records among providers and a separate Health Information Exchange which incorporates records from ambulatory practices and hospital discharges. Although this effort has been funded with an initial $5 million grant, this investment is dwarfed by the large investments that the innovative systems have made in information

technology and EHR.

The tremendous potential of “intelligent” information technology systems which improve outcomes through sets of evidence-based guidelines, alerts, warnings and care coordination can only be realized if regional interoperability becomes a reality.

RECOMMENDATION: All providers should seek to join the existing regional electronic health records (EHR) effort making regional interoperability a priority. In addition, providers should coalesce to establish metrics for comparisons at the physician level. The region can use the benchmarks set by the CMS for hospitals, by DOH for SNFs, National Committee on Quality Assurance’s Healthcare Effectiveness Data and Information Set measures for ambulatory practices and clinics, and CMS’s Physician Quality Reporting System for physicians. This data should be collected, formatted and made public on an annual or biannual basis. The large investment would be facilitated by large scale system integration.

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